1164609061 NPI number — CHRISTY LAU JOUBERT PA-C

Table of content: CHRISTY LAU JOUBERT PA-C (NPI 1164609061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164609061 NPI number — CHRISTY LAU JOUBERT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOUBERT
Provider First Name:
CHRISTY
Provider Middle Name:
LAU
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164609061
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3495 PIEDMONT ROAD, NE
Provider Second Line Business Mailing Address:
NINE PIEDMONT CENTER
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-364-7070
Provider Business Mailing Address Fax Number:
770-972-2998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 TORON PARK LAKE
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE TORON PARK MEDICAL CENTER
Provider Business Practice Location Address City Name:
KENNESACO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-514-5401
Provider Business Practice Location Address Fax Number:
770-874-5433
Provider Enumeration Date:
01/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  005252 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9113148 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 106618900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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